Plastic surgeons have been referring patients to hyperbaric chambers for decades — to rescue a mastectomy flap turning dusky, to salvage a replanted finger, to coax a radiated jaw wound into healing. Yet until now, no one had systematically pulled together what the specialty’s entire published record actually shows. A team from UCLA’s David Geffen School of Medicine and Division of Plastic and Reconstructive Surgery has done exactly that, publishing what it describes as the first comprehensive systematic review of hyperbaric oxygen therapy (HBOT) across plastic and reconstructive surgery in Plastic and Reconstructive Surgery Global Open, the open-access journal of the American Society of Plastic Surgeons.
The picture that emerges is a familiar one in hyperbaric medicine: outcomes that look impressive in individual series, wrapped in an evidence base too thin and too inconsistent to settle the questions that matter most — who should be treated, when, and at what dose.
What 56 years of studies add up to
The reviewers screened 355 records and ultimately included 18 studies spanning 1967 to 2023, covering 1,281 patients — 786 treated with HBOT and 495 controls. The most common indication was compromised flaps and grafts (seven studies), followed by crush and extremity injuries (four) and chronic wounds (three). Reported results were striking on their face: flap and graft survival ranged from 64% to 100%, limb salvage reached 81% to 94.4%, infection control improved in up to 82.6% of cases, and wound-healing rates ran from 43.9% to 100%.
But the pooled meta-analysis tells a more restrained story. Across the studies with control groups, HBOT was associated with a 52% relative reduction in complications — yet the confidence interval was so wide (odds ratio 0.48; 95% CI 0.09–2.66) that the result did not reach statistical significance (P = 0.40), and heterogeneity between studies was very high (I² = 82.4%). In plain terms: the trend favors HBOT, but the studies are too different from one another to prove it.
The design mix explains why. Two-thirds of the included studies were case series; only 11% were randomized controlled trials. Most of the evidence sat at level III–IV on the American Society of Plastic Surgeons’ rating scale, and risk-of-bias assessments flagged everything from uncontrolled confounding to incomplete outcome reporting. One cohort study even found a marginally significant increase in postoperative infection among patients who had received HBOT before free-flap reconstruction for mandibular osteoradionecrosis — a finding the reviewers attribute to selection bias, since chambers tend to be reserved for the sickest, most refractory cases.
Timing may be the real variable
Buried in the data is the review’s most actionable signal: when treatment starts may matter as much as whether it happens at all. In studies of severe hand injuries and limb-threatening trauma, HBOT begun within roughly six hours of surgery — sometimes with multiple sessions in the first 24 hours — produced salvage rates of 81% for replanted fingers and 100% for palm revascularizations. In contrast, one series of compromised mastectomy flaps did not start HBOT until an average of nine and a half days postoperatively. Even then, 22 of 25 breasts (88%) were salvaged — but another flap study found a significant negative correlation between delay and salvage success.
No study identified a cutoff beyond which HBOT stops working, and the reviewers note that protocols varied wildly: pressures from 2.0 to 3.0 ATA, sessions of 30 to 120 minutes, and total courses ranging from six to 60 treatments, sometimes given prophylactically before and after surgery, sometimes only after a flap began to fail.
Where this fits in the regulatory landscape
The findings land squarely on indications where HBOT already has official standing. The FDA recognizes hyperbaric oxygen for compromised skin grafts and flaps, crush injury and other acute traumatic ischemias, chronic refractory osteomyelitis, and delayed radiation injury — the very scenarios dominating this review. Medicare’s National Coverage Determination 20.29 reimburses HBOT for many of the same conditions, which is part of why hospital-based wound-care and reconstructive programs can offer it at all.
That regulatory clarity has limits, and they matter. The FDA’s consumer guidance is explicit that HBOT is not cleared for the long list of conditions marketed by wellness clinics, and its August 2025 letter to health care providers warned of serious injuries and deaths linked to improper use of hyperbaric devices — including fires — urging strict adherence to manufacturer instructions and facility safety standards. None of the plastic-surgery studies in this review were powered to detect rare catastrophic events, but the safety backdrop reinforces the reviewers’ core point: this is an adjunct to be delivered in accredited hospital settings, on defined protocols — not an open-ended wellness service.
The takeaway for surgeons and patients
The UCLA team’s conclusion is deliberately measured: HBOT “shows benefit as an adjunct in plastic surgery, particularly for chronic wounds, limb preservation, and flap or graft salvage,” but standardized trials are needed to define optimal timing, dosing, and patient selection. For a specialty where the alternative to a successful salvage is often another operation — or an amputation — even a therapy with imperfect evidence earns its place in the toolkit. What this review makes clear is that after five decades of use, plastic surgery still owes its patients the randomized trials that would turn promising salvage statistics into proof.
Sources
- Current Use of Hyperbaric Oxygen Therapy in Plastic Surgery: A Systematic Review (Plast Reconstr Surg Glob Open, 2026)
- FDA — Hyperbaric Oxygen Therapy: Get the Facts
- FDA — Follow Instructions for Safe Use of Hyperbaric Oxygen Therapy Devices: Letter to Health Care Providers (2025)
- CMS — National Coverage Determination 20.29: Hyperbaric Oxygen Therapy